A qualitative study using a critical review of the literature and semi structured interviews with a small sample of Hospice Chief Executives explored their perceptions of the impact and effect of the national policy agenda on their organisation and hospice care in England.

The findings from the research indicate that hospice services continue to be influenced by their history and legacy. The ‘arrogance’ of hospice organisations viewing themselves as ‘set apart’ and in charge of their own destiny is set to be challenged by the new world of commissioning. Operating outside the National Health Service but dependent on partial funding to provide end of life care services to patients, they are trying to be innovative, challenge existing cultural norms, engage a wider populace and redefine the parameters of what they can offer while maintaining ‘independence’.

The national drive to support care in the community is refocusing hospice care into the community with outreach support and engagement with other provider services, rather than inpatient provision. This integrated approach poses conceptual difficulty for hospice staff.

The balancing of the historic context with external demands of an ever changing health care landscape focused the CEOs interviewed to discuss the change in identity of hospice from a ‘building’, to a community outreach service with access to specialist resources- a significant turning point. Increased visibility impacted on how hospice was viewed by the wider healthcare economy, rather than, ‘do gooding’ little charities, but as part of whole service provision. The struggle between independence and integration is a tension for hospice particularly related to outcomes and demonstrating the unique role of palliative and EoLC.

The study also highlighted how policy has influenced hospice to reframe as small business units taking a commercial view of their service configuration which all CEOs viewed as a challenge.